Andreas Gerber

School-based prevention: Effects on obesity and physical performance after 4 years

Abstract Juvenile obesity is increasing worldwide. Preventive strategies are warranted. The school-based Childrens Health Interventional Trial (the CHILT Project) combines health education and physical activity for children. The effect on obesity and physical performance was studied after four years in 12 primary schools compared with five control schools. Anthropometric data were recorded. Physical performance was measured by a coordination test for children (balancing backwards, one-legged obstacle jumping, lateral jumping, sideways movements) and a 6-min run (endurance). No difference in the prevalence and incidence of overweight and obesity was found between the intervention and control schools before and after the intervention. Remission of overweight was higher in the intervention schools (23.2 vs. 19.2%), but not significant. An increase in coordination related to lateral jumping and balancing backwards was apparent in the intervention schools (30.6, s = 10.8 vs. 26.1, s = 10.8, P = 0.005; 21.8, s = 11.8 vs. 19.4, s = 11.7, P = 0.007), and the increase in endurance performance tended to be higher in intervention schools (100.8, s = 122.7 vs. 92.8, s = 126.0, P = 0.055), adjusted for age, sex, baseline test result, and body mass index at final examination. Therefore, preventive intervention in primary school offers the possibility to improve physical performance in children. The prevalence and incidence of obesity were not affected.

Reflections on the changing face of German pharmaceutical policy: how far is Germany from value-based pricing?

Statutory health insurance (SHI) in Germany serves 90% of the population. Predicted SHI deficits for 2010 and 2011, of h7 billion and h10–12 billion, respectively, resulted in a law freezing the prices of drugs already in the market (which came into effect on 1 August 2010). The subsequent ‘Act to Reorganize the Pharmaceuticals’ Market in the SHI System’ (Gesetz zur Neuordnung des Arzneimittelmarktes in der gesetzlichen Krankenversicherung [AMNOG]) passed through Federal Parliament on 11 November 2010 and came into effect on 1 January 2011. What implications does this have for the health economic evaluation of new drugs in Germany? We delineate where and how health economic evaluation will be tied in with decision making on drug prices, and also explore how close the new law will come to value-based pricing, a question verymuch in discussion in other healthcare systems.

Financial incentives in the German statutory health insurance: new findings, new questions

OBJECTIVES This paper presents findings of a mandatory three-year evaluation of a prevention bonus scheme offered in the German Statutory Health Insurance (SHI). Its objective is to describe the rationale behind the programs, analyze their financial impact and discuss their implications on potentially conflicting goals on solidarity and competition. METHODS The analysis included 70,429 insured enrolled in a prevention bonus program in a cohort study. The intervention group and their matched controls were followed for a three-year period. Matching was performed as nearest neighbor matching. The economic analysis comprised all costs relevant for Sickness Funds (SF) in the SHI and was carried out from a SHI perspective. Differences in cost trends between the intervention and the control group were examined applying the paired t-test. RESULTS Regarding mean costs there was a significant difference between the two groups of euro177.48 (90% CI [euro149.73; euro205.24]) in favor of the intervention group. If program costs were considered cost reductions of euro100.88 (90% CI [euro73.12; euro128.63]) were obtained. CONCLUSIONS The uptake of a prevention bonus program led to cost reductions in the intervention group compared to the control group even when program costs were considered. However, the results must be interpreted with caution as in addition to financial aspects, socio-economic and health-status, selection bias and the function and use of bonus programs as marketing tools, as well as their long-term sustainability should be considered in future assessments.

Electronic medical record use in pediatric primary care.

OBJECTIVES To characterize patterns of electronic medical record (EMR) use at pediatric primary care acute visits. DESIGN Direct observational study of 529 acute visits with 27 experienced pediatric clinician users. MEASUREMENTS For each 20 s interval and at each stage of the visit according to the Davis Observation Code, we recorded whether the physician was communicating with the family only, using the computer while communicating, or using the computer without communication. Regression models assessed the impact of clinician, patient and visit characteristics on overall visit length, time spent interacting with families, and time spent using the computer while interacting. RESULTS The mean overall visit length was 11:30 (min:sec) with 9:06 spent in the exam room. Clinicians used the EMR during 27% of exam room time and at all stages of the visit (interacting, chatting, and building rapport; history taking; formulation of the diagnosis and treatment plan; and discussing prevention) except the physical exam. Communication with the family accompanied 70% of EMR use. In regression models, computer documentation outside the exam room was associated with visits that were 11% longer (p=0.001), and female clinicians spent more time using the computer while communicating (p=0.003). LIMITATIONS The 12 study practices shared one EMR. CONCLUSIONS Among pediatric clinicians with EMR experience, conversation accompanies most EMR use. Our results suggest that efforts to improve EMR usability and clinician EMR training should focus on use in the context of doctor-patient communication. Further study of the impact of documentation inside versus outside the exam room on productivity is warranted.

What can we learn from German health incentive schemes

Incentives aimed at changing individual health behaviours are well established in Germany. Harald Schmidt, Andreas Gerber, and Stephanie Stock describe how they work and discuss some of the difficulties

Is prevention of atopic eczema with hydrolyzed formulas cost‐effective? A health economic evaluation from Germany

To cite this article: Mertens J, Stock S, Lüngen M, Berg AV, Krämer U, Filipiak‐Pittroff B, Heinrich J, Koletzko S, Grübl A, Wichmann H‐E, Bauer C‐P, Reinhardt D, Berdel D, Gerber A. Is Prevention of Atopic Eczema with Hydrolyzed Formulas Cost‐Effective? A Health Economic Evaluation from Germany. Pediatr Allergy Immunol 2012: 23: 597–604.

Preliminary analysis of short term financial implications of a prevention bonus program: First results from the German statutory health insurance

SummaryObjectives:With the implementation of the Health Care Modernization Act in 2004 sickness funds in Germany were given the opportunity to award bonuses to their insured for healthpromoting behavior. The aim of this study was to investigate the financial implications of a prevention bonus program from a sickness fund perspective.Method:The investigation was designed as a controlled cohort study (matched pair study) comprising 70,429 members in each group. Matching criteria were sex, postal code, insurance status, and cost categories for health care utilization. Insured opted into the program on a voluntary basis. The program consisted of interventions featuring primary prevention, modest exercise and immunization. Differences in cost trends between the two groups were examined using the paired t-test.Results:A reduction in mean costs of 241.11 € per active member for the year 2005 (90 % CI = 348.70, 133.52; p-value < 0.001) could be achieved in the intervention group compared to the control group. When costs for the implementation of the program and the bonus payments were taken into account, there was a saving of 97.14 € per active member for the year 2005.Conclusions:Preliminary results of a prevention bonus program in the German Statutory Health Insurance suggest a decrease in mean health care spending per enrollee. These effects may increase with time as long term effects of prevention become effective. However, further research is needed to understand how much of these short term cost reductions can be attributed to the program itself rather than to possible confounders or volunteer bias and how the short term savings may be accrued.

European Academy of Paediatrics Research in Ambulatory Setting network (EAPRASnet): a multi‐national general paediatric research network for better child health

BACKGROUND In 2008, the European Academy of Paediatrics launched a paediatric-based research network - EAPRASnet (European Academy of Paediatrics Research in Ambulatory Setting network). The network has recruited primary care and general paediatricians from European and Mediterranean countries. METHODS Every paediatrician joining the network has been asked to complete a recruitment survey. The aims of the survey were to characterize paediatricians demographics, practice arrangements and patients demographics, to define main incentives for research, and to learn what paediatricians view as unsolved issues that need to be studied. RESULTS A total of 156 paediatricians from 19 countries were recruited with 144 completing the questionnaire (92%). Majority of respondents (89%) were general paediatricians for more than half of their time. Practice arrangement of 47% of paediatricians was solo practice, with 40% in group practice. Electronic medical records were being used by 72% of respondents. Over 70% of the paediatricians had more than 1000 patients under their clinical care, and patients younger than 6 years old contributed nearly half of the patient population. Areas of most interest for research were: quality of care indicators, communication with parents, obesity, attention deficit hyperactivity disorder and effective well child care. Main incentives for participation in a research project were interest in the topic (81%) and effort to improve quality of care (71%). Lack of time was the leading reported obstacle for research activity (72%). EAPRASnet is growing, and the networks structure, operation and funding are described. Methods for joining the network and the process of study development are presented. CONCLUSION A core group of EAP general paediatricians are committed to research in their practices. The information gathered will serve for future planning of research projects in the EAPRASnet to harmonize and optimize the care given to children in the primary care setting in Europe.

Evidenz der Wirksamkeit internationaler Präventionsmaßnahmen und Auswirkungen auf ein deutsches Präventionsgesetz

ZusammenfassungHintergrund und Ziel:In Deutschland werden seit Jahren Anstrengungen unternommen, ein Präventionsgesetz abzufassen und zu verabschieden. Trotz wechselnder politischer Mehrheiten konnte bisher kein Konsens über eine konkrete Umsetzung der Prävention erzielt werden. Der Beitrag geht der Frage nach, ob ein Grund für das wiederholte Scheitern auch der Mangel an Nachweisen des Effekts von Interventionen in Prävention und Gesundheitsförderung sein kann.Methodik:Im Anschluss an eine systematische Literatursuche wurden Effektivität und Qualität von Studien zu Interventionen in Prävention und Gesundheitsförderung bewertet. Untersucht wurden exemplarisch Interventionen der Jahre 1990–2006 aus den Bereichen Depression bei Kindern und Jugendlichen, Bewegung im betrieblichen Setting, Ernährung bei Kindern und Jugendlichen im schulischen Setting und Rauchentwöhnung bei Schwangeren. Die Studien wurden in jeweils einem von 13 Ländern durchgeführt, die einen mit Deutschland vergleichbaren sozioökonomischen Status haben.Ergebnisse:Für den Bereich Depression wurden 18, für Bewegung 26, für Ernährung 23 und für Rauchen 34 Studien bewertet. Von 26 Interventionen im Bereich Bewegung waren sechs effektiv (23,1%), von 18 Interventionen im Bereich Depression war eine effektiv (5,6%), von 23 gesichteten Interventionen im Bereich Ernährung waren sieben effektiv (30,4%), und im Bereich Rauchen schlossen neun Interventionen (26,5%) mit einem positiven Effekt ab. Nimmt man die Qualität des Studiendesigns wie der Durchführung der Interventionen als weiteres Kriterium dazu, bleiben von den effektiven Studien nur noch eine im Bereich Bewegung im Betrieb, zwei im Bereich Ernährung, drei im Bereich Rauchen und keine im Bereich Depression übrig.Schlussfolgerung:In vier exemplarisch ausgewählten Feldern konnten nur sechs von insgesamt 101 (5,9%) untersuchten internationalen Studien auch bei entsprechender Qualität des Studiendesigns und der Interventionsdurchführung einen Effekt zeigen. Angesichts dieses Ergebnisses könnte derzeit eine Verteilung von Ressourcen in der Prävention kaum auf einer verlässlichen Grundlage erfolgen, was die Verabschiedung eines Präventionsgesetzes möglicherweise erschwert. Ein zukünftiges Präventionsgesetz sollte daher wesentlichen Wert auf die Evaluation des Effekts wie der Qualität von Maßnahmen legen, um Fehlallokationen zu vermeiden.AbstractBackground and Purpose:Efforts have been undertaken to devise and pass an Act of Prevention in Germany. To date, no consensus could be reached with changing political majorities in parliament. Hence, the authors ask the question whether the lack of evidence in prevention and health promotion could also be contributing to this delay.Methods:After a systematic search of the literature on prevention and health promotion in nutrition, exercise, depression, and smoking, all retrieved studies were evaluated in terms of their effect as well as the quality of study design like prior power calculation and intervention like documentation of process or participation of intended group. For inclusion, studies had to be undertaken in one of 13 countries that have a socioeconomic standard of living comparable to Germany. The authors of this article exemplarily included studies from the following focus areas into the systematic review: prevention of depression among children and adolescents, exercise in the work environment, nutrition for children and adolescents, and smoking cessation programs among pregnant women, all from 1990 to 2006.Results:The authors retrieved 18 studies on prevention of depression among children and adolescents, 26 on exercise in the work environment, 23 on nutrition for children and adolescents, and 34 on smoking cessation programs among pregnant women. Six out of 26 on exercise had a positive effect (23.1%), one out of 18 on depression (5.6%), seven out of 23 in the field of nutrition (30.4%), and nine out of 34 smoking cessation programs (26.5%). If one takes into account the quality of study design and intervention as a marker for the reliability and validity of results, one intervention on exercise, two on nutrition, three on smoking and none on depression would remain with a positive effect.Conclusion:In four exemplarily selected fields only six out of a total of 101 international studies (5.9%) had an effect, if one also ties in quality of study design and intervention. With regard to this result, allocation of resources for prevention and health promotion would be highly ambiguous without sufficient evidence. This condition might contribute to the deferment of an Act of Prevention in the German legislation. For the future, the authors strongly urge that the Act of Prevention takes into account the evaluation both of effects and quality of any intervention in order to prevent false allocation of resources.BACKGROUND AND PURPOSE Efforts have been undertaken to devise and pass an Act of Prevention in Germany. To date, no consensus could be reached with changing political majorities in parliament. Hence, the authors ask the question whether the lack of evidence in prevention and health promotion could also be contributing to this delay. METHODS After a systematic search of the literature on prevention and health promotion in nutrition, exercise, depression, and smoking, all retrieved studies were evaluated in terms of their effect as well as the quality of study design like prior power calculation and intervention like documentation of process or participation of intended group. For inclusion, studies had to be undertaken in one of 13 countries that have a socioeconomic standard of living comparable to Germany. The authors of this article exemplarily included studies from the following focus areas into the systematic review: prevention of depression among children and adolescents, exercise in the work environment, nutrition for children and adolescents, and smoking cessation programs among pregnant women, all from 1990 to 2006. RESULTS The authors retrieved 18 studies on prevention of depression among children and adolescents, 26 on exercise in the work environment, 23 on nutrition for children and adolescents, and 34 on smoking cessation programs among pregnant women. Six out of 26 on exercise had a positive effect (23.1%), one out of 18 on depression (5.6%), seven out of 23 in the field of nutrition (30.4%), and nine out of 34 smoking cessation programs (26.5%). If one takes into account the quality of study design and intervention as a marker for the reliability and validity of results, one intervention on exercise, two on nutrition, three on smoking and none on depression would remain with a positive effect. CONCLUSION In four exemplarily selected fields only six out of a total of 101 international studies (5.9%) had an effect, if one also ties in quality of study design and intervention. With regard to this result, allocation of resources for prevention and health promotion would be highly ambiguous without sufficient evidence. This condition might contribute to the deferment of an Act of Prevention in the German legislation. For the future, the authors strongly urge that the Act of Prevention takes into account the evaluation both of effects and quality of any intervention in order to prevent false allocation of resources.

The German Coronary Artery Disease Risk Screening Model: development, validation, and application of a decision-analytic model for coronary artery disease prevention with statins.

Background. Coronary artery disease (CAD) is a major cause of death in industrial countries, leading to high health-related costs and decreased quality of life. Objective. To develop and validate a decision-analytic model for CAD risk screening in Germany (German Coronary Artery Disease Screening Model). Design. Markov model. Target Population. Age- and gender-specific cohorts of the German population. Data Sources. Mortality rates posted by the German Federal Statistical Office, the German Health Survey, social health insurance institutions, the MONICA Augsburg study, and the literature. Time Horizon. Lifetime. Interventions. CAD risk screening for high-risk individuals using Framingham risk equation and use of statins as the primary preventive measure, compared with a setting without screening. Outcome Measures. Life-years (LY) gained, quality-adjusted life-years (QALYs) gained. Results. The model-based CAD incidence corresponds well with empirical data from the MONICA Augsburg study. Health outcomes depend on the screening threshold (cutoff value of Framingham 10-year risk) and on the age and gender of the cohort screened (0.03 to 0.26 LYs and 0.06 to 0.42 QALYs gained per person screened in cohorts of 50- and 60-year-old men and women, respectively). Conclusions. The model provides a valid tool for evaluating the long-term effectiveness of CAD risk screening in Germany. Using statins as a primary prevention intervention for CAD in high-risk individuals identified by screening could improve the long-term health of the German population.